Privacy Notice

NORTHERN AVENUE EYE CARE NOTICE OF PRIVACY PRACTICES

To our patients: This notice describes how health information about you (as a patient of this practice) may be used and disclosed, and how you can get access to your health information. This is required by the Privacy Regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

Our commitment to your privacy:Our practice is dedicated to maintaining the privacy of your health information. We are required by law to maintain the confidentiality of your health information. We realize that these laws are complicated, but we must provide you with the following important information:How we may use and disclose your health information?Your privacy rights?Our obligations concerning the use and disclosure of your health information?

The following categories describe the different ways in which we may use and disclose your health information.

1. Treatment. Physicians and staff may use or disclose your health information in order to treat you or to assist others in your treatment. Additionally, we may disclose your health information to others who may assist in your care, such as your spouse, children, or parents.2. Payment. Our practice may use your health information to bill and collect payment for the services you receive from us. We may provide your insurer with details regarding your treatment to determine if your insurer will cover, or pay for, your treatment. We also may use and disclose this information to obtain payment from third parties that may be responsible for such costs, such as family members. Also, we may use your health information to bill you directly for services and items.3. Health care operations. We may need to use and disclose your health information to be able to run our practice at the highest clinical standards and as effectively as possible. This could be used to evaluate the performance of our physicians and staff, to determine if our treatment plans are effective, or determine if there are other services we should be offering. We may also compare our clinical data with other practices, review it with medical students, medical faculty, technicians, and others for teaching and learning purposes. We will strive to remove information that identifies you from this medical information.4. Disclosures required by law. Our practice will use and disclose your health information when we are required to do so by federal, state, or local law.5. Appointment Reminders and Sign-In Sheets. We may want to call you by phone for reminder purposes and leave a message on your answering machine at home, work, or with a family member.We will also use a sign in sheet at the front desk for purposes of logging our patients as they arrive. We will require your name only on this sign in sheet.Northern Avenue Eye Care will conduct patient group educational sessions for our patients.Specific questions relating to your individual medical issues will be addressed in private.You can request that our practice communicate with you about your health and related issues in a particular manner. For instance, you may wish to be contacted at work during business hours rather than home. We will accommodate reasonable requests. We will enlist the help of a translator (including ASL) if needed. This person may be your own family member, neighbor, or friend who accompanies you. This person would be privy to some of your health information.You can request a restriction in our use or disclosure of your health information for treatment, payment, or health care operations. Additionally, you have the right to request that we restrict our disclosure of your health information to only certain individuals involved in our care or the payment for your care, such as family members and friends. We are not required to agree to your request however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you.Any restrictions need to be given to Northern Avenue Eye Care in writing.The following circumstances may require us to use or disclose your health information:

1. To public health authorities and health oversight agencies that are authorized by law to collect information.2. Lawsuits and similar proceedings in response to a court or administrative order.3. If asked to do so by a law enforcement official.4. When necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. We will only make disclosures to a person or organization able to help prevent the threat.5. If you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate authorities.6. To federal officials for intelligence and national security activities authorized by law.7. To correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official.8. For Workers Compensation and similar programs.

Your rights regarding your health information:

1. Communications. You can request that our practice communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. We will accommodate reasonable requests.2. You can request a restriction in our use or disclosure of your health information for treatment, payment, or health care operations. Additionally, you have the right to request that we restrict our disclosure of your health information to only certain individuals involved in your care or the payment for your care, such as family members and friends. WE are not required to agree to your request however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you.3. You have the right to inspect and obtain a copy of the health information that may be used to make decisions about you, including patient medical records and billing records, but not including psychotherapy notes. You must submit your request in writing to Northern Avenue Eye Care, Compliance Officer at 2337 W. Northern Ave., Phoenix, AZ 85021.4. You may ask us to amend your health information if you believe it is incorrect or incomplete, and as long as the information is kept by or for our practice. To request an amendment, your request must be made in writing and submitted to Northern Avenue Eye Care, Compliance Officer at 2337 W. Northern Ave., Phoenix, AZ 85021. You must provide us with a reason that supports your request for amendment. Northern Avenue Eye Care has 60 days to respond to your request.5. Right to a copy of this notice. You are entitled to receive a copy of this notice of privacy practices. You may ask us to give you a copy of this notice at any time. To obtain a copy of this notice, contact Northern Avenue Eye Care Compliance Officer at 602-995-8848.6. Right to file a complaint. If you believe your privacy rights have been violated, you may file a complaint with our practice or with the Secretary of the Department of Health and Human Services. To file a complaint with our practice, contact Northern Avenue Eye Care, Compliance Officer at 602-995-8848. All complaints must be submitted in writing to 2337 W. Northern Ave., Phoenix, AZ 85021. You will not be penalized for filing a complaint.7. Right to provide an authorization for other uses and disclosures. Our practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. This authorization stays in effect until you revoke it.

If you have any questions regarding this notice or our health information privacy policies, please contactNorthern Avenue Eye Care, Compliance Officer at 602-995-8848.